Surgical treatment of multiple magnet ingestion by children: A single-center experience from China

Background: The incidence of magnet ingestion in children has escalated concurrent with the rise in popularity of magnetic playthings, bearing the capacity to induce substantial morbidity. Aim: The objective of this study was to encapsulate our accumulated expertise in handling pediatric cases featuring multiple magnetic foreign bodies within the gastrointestinal tract sometimes necessitating surgical intervention, as well as to formulate a clinical management algorithm. Methods: This was a retrospective review of patients with multiple magnetic foreign bodies in the digestive tract, admitted to Shenzhen Children’s Hospital, between January 2018 and December 2022. Results: A total of 100 cases were included in this study, including 66 males and 34 females. The main clinical manifestation ns were abdominal pain and vomiting. All patients had abdominal x-ray, all of which indicated foreign bodies in the digestive tract. 33 patients had to undergo a surgical intervention. Among these cases, the gastrointestinal complications occurred in 31 patients, including gastric rupture (n = 9), intestinal obstruction (n = 11) and intestinal perforation (n = 30). Postoperative intestinal obstruction occurred in 6 children. There was no statistical significant difference in age and gender between the Surgical group and Non-surgical group, but the Surgical group had a higher number of magnets ([7.5(2-44) vs 4(2-20)], p = 0.009), a longer interval between time of misingestion to clinical visit ([48(7.2-480) vs 5(2-336)]hours, p < 0.001), and a longer length of hospital stay ([10(6-19) vs 2(1-8)]days, p < 0.001). Conclusions: Multiple magnet ingestion in children can lead to serious complications and carry severe risks. Timely diagnosis and effective treatment are crucial for managing such patients.

Aim: The objective of this study was to encapsulate our accumulated expertise in handling pediatric cases featuring multiple magnetic foreign bodies within the gastrointestinal tract sometimes necessitating surgical intervention, as well as to formulate a clinical management algorithm.
Methods: This was a retrospective review of patients with multiple magnetic foreign bodies in the digestive tract, admitted to Shenzhen Children's Hospital, between January 2018 and December 2022.
Results: A total of 100 cases were included in this study, including 66 males and 34 females.The main clinical manifestation ns were abdominal pain and vomiting.All patients had abdominal x-ray, all of which indicated foreign bodies in the digestive tract.33 patients had to undergo a surgical intervention.Among these cases, the gastrointestinal complications occurred in 31 patients, including gastric rupture (n = 9), intestinal obstruction (n = 11) and intestinal perforation (n = 30).Postoperative intestinal obstruction occurred in 6 children.There was no statistical significant difference in age and gender between the Surgical group and Non-surgical group, but the Surgical group had a higher number of magnets ([7.5(2-44)  vs 4(2-20)], p = 0.009), a longer interval between time of misingestion to clinical visit ([48(7.2-480)vs 5 (2-336)]hours, p < 0.001), and a longer length of hospital stay ([10(6-19) vs 2(1-8)]days, p < 0.001).approximately 5 mm in diameter, possess formidable magnetic properties.Once accidentally ingested, they could steadily attract one another, even though six layers of the bowel wall apart. 4After the restrictions on "Buckball" were lifted in the United States in 2016, the number of people undergoing surgery due to accidental ingestion of magnetic beads has increased significantly. 5Unfortunately, the current body of literature on the surgical treatment of multiple magnetic foreign bodies remains limited, lacking in robust, high-quality studies.The majority of published studies in this realm predominantly adopt a descriptive approach.In light of this, we present a large case series of magnet ingestion in pediatric patients, aiming to provide clinical experience in early diagnosis, rational management options, and preventive measures.

INTRODUCTION
Foreign bodies in the digestive tract of children have emerged as a prevalent global issue, ranking high among unintentional injuries. 1The array of objects unintentionally swallowed encompasses a range of everyday items, including coins, small toys, batteries, and magnets.Managing such incidents requires a multifaceted approach involving conservative treatment, emergency endoscopy, and surgical intervention. 2It's noteworthy that a mere 1% of cases necessitate surgical intervention due to foreign body retention or related complications. 3 In recent times, there has been a noticeable surge in the incidence of magnet ingestion, partly attributable to the soaring popularity of a mesmerizing toy named "Buckball" (Figure 1).These tiny spheres, measuring Surgical treatment of multiple magnet ingestion by children: A single-center experience from China records.The inclusion criteria required participants to be aged 14 years or younger and to have ingested two or more magnets.Exclusion criteria encompassed individuals older than 14 years, solitary magnet ingestion, and cases with incomplete medical documentation.Subsequently, comprehensive clinical data were collected from the included patients, encompassing demographic information, primary complaints, symptoms, physical manifestations, imaging findings, the duration between ingestion and admission, surgical procedures, outcomes, and follow-up details.The patients were divided into two groups based on whether they underwent surgery, namely the Surgical group and the Non-surgical group.Descriptive count data with normal distribution are represented by means ± standard deviation and the differences between two groups were evaluated by independent sample t test.While, data with non-normal distribution are represented by median (minimum-maximum), and the differences were evaluated by Mann-Whitney U test.The difference of gender distribution between two groups was evaluated by chi-square test.All reported p values are two-tailed, and statistical significance was set at P < 0.05.Statistical analysis was conducted employing IBM SPSS Statistics 23.0 (IBM Corp., Armonk, NY).This study obtained approval from the Medical Ethics Committee of the Shenzhen Children's Hospital (approval number 202200402).

RESULT General Data
Between January 2018 and December 2022, Shenzhen Children's Hospital received a total of 100 patients with multiple magnetic foreign bodies, out of which 33 had to undergo a surgical intervention.The magnetic foreign bodies encompassed 83 cases of Buckyballs and 17 cases involving other types of magnets (Table 1).The Non-surgical group, all children or parents were able to provide a comprehensive account of foreign body ingestion during the medical consultation.In the Surgical group, only 21 patients (63.6%) were able to provide a detailed history of foreign body ingestion.Compared to the Non-surgical group, the Surgical group had a longer interval between time of misingestion to clinical visit and higher number of magnets (Table 2).
Notably, within the Surgical group, 29 cases (84.8%) exhibited symptomatic manifestations, which included 20 cases of abdominal pain, 22 percentage of patients who had ingested Buckyballs has shown a general increasing trend over the years (Figure 2).The gender distribution exhibited a ratio of 4.9 males to every female.The age range spanned from 0.6 years old to 12 years old, with a median age of 4.8 years old.Compared with the Non-surgical group, there was no significant difference in age and gender (Table 2).

Clinical Manifestations
The number of ingested magnetic foreign bodies ranged from 2 to 44, with a median of 4.0.In the

Clinical Management and Prognosis
According to the radiographs, in 30 cases, the magnets were located in the upper digestive tract, so gastroduodenoscopies were performed.

Image Analysis
All cases underwent plain abdominal radiography, which confirmed the presence of multiple magnetic foreign bodies.The radiographic depiction of two examples of ingested magnets is  VOL.2024 / ART. 4 Surgical treatment of multiple magnet ingestion by children: A single-center experience from China individuals experienced perforation within their digestive tracts, with the number of gastrointestinal perforations ranging from 0 to 10 and a median of 2.9.Notably, the small intestine emerged as the most frequent site for magnet adhesion.Other gastrointestinal complications included intestinal obstruction (11 cases), intestinal adhesion (25 cases), intestinal volvulus (1 case), and intestinal necrosis (1 case).The primary surgical approach entailed the removal of the foreign body through the original perforation site, followed by perforation repair (Figures 5 and 6).In cases where the foreign body could not be successfully extracted, an incision was made in the digestive tract to facilitate its removal, followed by subsequent repair.In 1 instance, due to the proximity of the foreign body to the appendix, the of foreign objects in the abdomen.Subsequently, the patients were transferred to surgery.The remaining 24 cases had all foreign bodies successfully removed, and they suffered no gastrointestinal complications.70 cases' magnets were located in the lower digestive tract.Among them, 27 patients exhibited signs of severe gastrointestinal complications and had to undergo surgical intervention.For patients without signs of severe gastrointestinal complications, conservative treatment was employed, such as series X-rays taken 6-12 hours apart and close observation.All patients receiving conservative treatment successfully passed the magnets without experiencing serious gastrointestinal complications.
All cases in the Surgical group ultimately underwent laparotomy (Table 3).Out of these, 31  All patients recovered uneventfully and were discharged home.Compared to the Non-surgical group, the Surgical group had a significantly longer length of hospital stay (Table 2).Remarkably, appendix was incised to extract the foreign object, after which the appendix itself was removed.6 cases initially underwent endoscopic treatment, which was subsequently switched to surgical intervention due to perforation or the inability to completely extract all foreign bodies.Additionally, 6 cases initially began with laparoscopy but were later transitioned to open laparotomy.The specific  VOL.2024 / ART. 4 Surgical treatment of multiple magnet ingestion by children: A single-center experience from China approximately 2:1. 11This discrepancy can be attributed, in part, to the vivacious and mischievous disposition often associated with boys. 1 Moreover, it is plausible that divergent approaches to parental guidance between the genders also play a role. 1 Additionally, the constrained sample size within our study could be a contributing factor.In terms of age distribution, School-age children accounted for the highest proportion in this study.This may be attributed to factors such as the strong curiosity of school-age children and a lack of relevant safety knowledge.
In our study, the symptoms and signs in patients were mostly atypical, such as abdominal pain, vomiting, and abdominal tenderness.Similar circumstances have been reported by Zefov V et al. 12 Furthermore, some children or parents may not be able to provide a comprehensive account of foreign body ingestion during the medical consultation, which makes early diagnosis difficult. 7,13Therefore, clinicians need to handle patients suspected of ingesting magnets with extra caution.Perforation and obstruction were the most common gastrointestinal complications in this study, necessitating surgical intervention.Through comparative analysis, we found that the number of ingested magnets and the interval between time of misingestion to clinical visit may be associated with the occurrence of these complications.
In the current investigation, the diagnosis of all patients was accomplished through abdominal radiography.Employing orthogonal radiography aids in ascertaining both the quantity and placement of magnets, along with detecting potential complications such as intestinal obstruction. 6,9ntecedent studies have revealed the limitations of X-ray imaging in distinguishing magnets from other foreign objects, such as metallic items (e.g., coins) and inorganic substances (e.g., pearls). 14In cases of perforation, accurate diagnosis can prove elusive.However, for non-radiopaque foreign bodies like magnets, we still recommend abdominal X-ray as the preferred examination.The numerous merits of abdominal sonography, including its non-invasive attributes, exceptional portability, and the assessment of gastrointestinal complications. 1 Nonetheless, its diagnostic precision is dependable upon the expertise and experience of the physician. 15CT imaging has the capability to identify during a 6-month follow-up period, 6 children encountered episodes of intestinal obstruction, yet all instances were effectively resolved through conservative therapeutic measures.Encouragingly, there were no reported cases of repeated foreign body ingestion.

DISCUSSION
Children swallowing magnets is becoming a serious problem in public health that we need to pay attention to.Previous studies have shown that more and more children around the world are accidentally eating objects with magnets, and this problem keeps getting worse every year in many countries. 6,7This worrying trend is mainly because of the popularity of magnetic toys such as Buckyball.They are made of neodymium magnets, and are at least 30 to 50 times more powerful than traditional magnets.After multiple magnets were swallowed, they attracted each other tightly, resulting in local compression of the intestinal wall, ischemia, necrosis, perforation, peritonitis, internal fistula, intestinal obstruction and even death. 8In the study of Zheng Y et al, 45.1% of children who accidentally ate multiple magnets needed surgery. 9n addition, surgery exposing children to not only short and medium-term risks, such as anaesthetic complications and anastomotic leaks, but also the lifelong risks of subsequent complications, particularly adhesional bowel obstruction.Around 2010, Chinese sellers introduced Buckballs as educational toys, and kids loved them because they could learn while having fun.However, the attendant perils and deleterious ramifications of Buckballs have been distressingly overlooked. 10As the data gleaned from our meticulous analysis aptly illustrate, the patient tally continued its unrelenting ascent until 2020.Interestingly, after that, there was a noticeable decrease in the number of cases each year, which is a good sign.This decrease may be attributed to the increased awareness about the dangers of Buckballs.Nevertheless, we still cannot underestimate the dangers of Buckballs.Within the 100 cases comprising this cohort, the prevalence of males outweighs that of females considerably, constituting a substantial 66.0%.This figure is close to the male-to-female ratio observed in prior investigations, which typically stood at children who inadvertently ingested multiple magnets necessitated surgical intervention. 9Such surgical procedures predominantly encompass laparoscopic surgery and laparotomy. 15,16The former is the traditional surgical approach, suitable for all gastrointestinal foreign bodies.The latter, as indicated by Cai DT et al., can be employed for managing patients who have ingested foreign bodies for more than 2 weeks and exhibit milder clinical symptoms and signs, with the foreign body located in the small intestine. 10In instances of laparoscopic surgery, the metallic tips of laparoscopic instruments may facilitate intestinal obstruction, perforation, abdominal inflammation, and other associated complications.However, the contentious aspect surrounding CT employment in the diagnosis of digestive tract foreign bodies stems from its considerable cost.Therefore, doctors need to make choices based on the actual circumstances when further examining gastrointestinal complications.
The proper management strategies for cases involving the ingestion of multiple magnets bear profound significance in enhancing patients' overall outcomes.
In previous studies, an estimated fifty percent of the suggests their limited efficacy in deterring magnet ingestion. 7,22Consequently, the implementation of more stringent policies becomes imperative in safeguarding children from acquiring products containing high-power magnets.Simultaneously, the role of parental supervision emerges as a pivotal factor in mitigating injuries.
The study is limited by the retrospective nature of the data collection, relying on complete, and accurate records in patient case notes.The factor create the potential for selection bias.Secondly, while the data were collected from a tertiary center, it is important to acknowledge that the study sample size comprises only 100 cases.

CONCLUSION
The initial presentations of multiple magnet ingestion in pediatric cases often lack typical characteristics, but can result in severe complications, especially if their removal is delayed or if a large number of magnets are ingested.In our study sample, approximately one-third of patients who ingested multiple magnets experienced severe gastrointestinal complications, necessitating surgical intervention.It is imperative for pediatricians to maintain constant vigilance regarding the potential hazards associated with such conditions.Moreover, there is an urgent demand for more stringent regulatory measures to deter children from acquiring perilous magnetic products.

FUNDING
This work was supported by Guangdong High-level Hospital Construction Fund and Shenzhen Health and Medical Elite Talent Development Program (2022XKG066).
the identification of magnets. 17However, the mutual attraction between surgical instruments and magnets can exacerbate the operative complexity, extend the duration of the procedure, and potentially result in intestinal harm, minute perforations, and mesenteric lesions. 10Within our department, initially, 6 cases underwent laparoscopic surgery, which was later switched to laparotomy due to various reasons.Consequently, we still advocate for laparotomy as the primary choice.When confronted with the scenario of multiple magnet ingestions transpiring within the stomach or esophagus, endoscopic extraction may mitigate the necessity for surgical intervention in select cases, provided that the timeframe since ingestion does not surpass 12 hours. 9Prudent manipulation becomes paramount in this context, as imprudent handling runs the risk of gut perforation and subsequent leakage. 18In situations where children exhibit no severe symptoms and magnet migration beyond the stomach is suspected without signs of obstruction or perforation, a conservative approach can be adopted. 9,19This entails the administration of laxatives and the acquisition of sequential plain radiographs to monitor magnet movement while awaiting natural passage.Consequently, drawing upon the existing body of literature alongside our own clinical experiences, 15,[20][21][22][23][24][25][26] a flow chart was introduced for the management of multiple magnetic ingestions in the pediatric population (Figure 7).In the United States, the overturning of legislation pertaining to the ban of magnet products in 2016 resulted in a notable resurgence of magnet ingestion cases. 5This occurrence underscores the considerable impact that shifts in national policy can exert on the incidence of multiple magnet ingestions.In China, magnetic toys, such as Buckballs, are readily obtainable by children through physical stores and online platforms. 21espite the presence of warning signs, evidence

Figure 2 .
Figure 2. The number of patients with multiple magnets ingestion and the proportion of patients with Buckyball ingestion at Shenzhen Children's Hospital from 2018 to 2022.

Figure 3 .
Figure 3. Anterior and lateral X-ray views of a patient who ingested a string of magnetic beads.

Figure 4 .
Figure 4. Anterior and lateral X-ray views of a patient who ingested a small number of magnetic beads.
multiple magnet ingestion by children: A single-center experience from China reasons for this change included challenges in locating the foreign body, suspicion of intestinal necrosis, significant abdominal adhesions, and evident intestinal dilation.

Figure 6 .
Figure 6.19 magnetic beads with tissue in between.

Figure 7 .
Figure 7. Suggested algorithm for management of multiple magnet ingestions in the pediatric population.

Table 1 . Clinical features of patients with multiple magnetic foreign body ingestion.
VOL. 2024 / ART.4Surgical treatment of multiple magnet ingestion by children: A single-center experience from China